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NURS 2910 > Ch. 1 Introduction to Assessment > Flashcards

Ch. 1 Introduction to Assessment Flashcards

1
Q

What is the nursing process?

A

ADPIE! Assessment, diagnosis, plan, implement, evaluate

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2
Q

The nursing process is linear T or F

A

False

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3
Q

The first foundational step of the nursing process

A

Assessment!

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4
Q

Critical Thinking

A
  • The process of intentional and reflective judgment about nursing problems, where the focus is on clinical decision-making, to provide safe and effective care.
  • thinks beyond “what if”
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5
Q

Grounding/centering

A

focus and put energy back into the earth

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6
Q

Creating intentions

A

Getting focused and ready to see the patient

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7
Q

Preassessment phase includes

A

Heart centering, grounding/centering, and creating intention

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8
Q

Be CLEAR acronym

A
  • Center yourself, Listen Wholeheartedly, Empathize, Attention, Respect
  • Takes all 5 senses( verbal and non-verbal)
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9
Q

Holistic Care values

A
  1. Holistic philosophy, theories, and ethics
  2. Holistic nurse self-reflection, self-development and self-care
  3. Holistic Caring Process
  4. Holistic communication, therapeutic relationships, and healing environment and cultural care
  5. Holistic education and research
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10
Q

Characteristics of collaborative professional communication

A
  • assertive communication> be assertive and direct
  • rounding
  • hand off report
  • SBAR documentation
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11
Q

Each individual is unique T or F

A

True

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12
Q

The art of listening includes

A
  • being client focused
  • Body posture
  • use all senses & active listening
  • be careful not to act too quickly
  • requires energy and concentration
  • Art of not knowing> what isn’t being said?
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13
Q

Nonverbal Communication

A

No words just actions
- body posture
- facial expressions
- Gait/ movement

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14
Q

Health Assessment

A

A systematic method of collecting and analyzing data for the purpose of planning client-centered care

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15
Q

Assessment begins…

A
  • at the first moment, the nurse meets the client
  • first impressions
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16
Q

Head-to-toe approach

A

starts at head and neck and progresses down the body, examining the feet last

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17
Q

Why learn assessments?

A
  • health assessment is a comprehensive assessment of the physical, mental spiritual, socioeconomic, and cultural status of an individual
  • focuses on the functional abilities and physical responses to illness another structure
  • assessment= painting a picture
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18
Q

Components of a health assessment

A
  • Health history
  • Physical examination
  • Documentation of data
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19
Q

health history

A

data gathered about the clients health history, health conditions and diseases, family health history, lifestyle and risk appraisal, and life stress review

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20
Q

Physical examination

A

a systematic approach, same order each time. Head-to-toe approach

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21
Q

Documentation of data

A

Data collected from health assessments must be documented so that other healthcare providers can use the information

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22
Q

Subjective data

A

symptoms, what one can’t see
- what the client says
- cannot feel or see as a provider

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23
Q

Objective data

A

gathered data from the assessment
- what you can see ex. vital signs/ test data

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24
Q

Comprehensive Physical Assessment

A

Includes health history, interview, and a complete head-to-toe examination of every body system

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25
Q

Focused Assessment

A

An assessment that pertains to a particular topic, body part, or functional ability rather than overall health status and it adds to the database created by the comprehensive assessment

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26
Q

System-Specific Assessment

A

A focused assessment limited to one body system
ex. resp. distress/ cardiac

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27
Q

Ongoing assessment

A

An assessment that is performed as needed, after the initial database is completed and ideally at every interaction with the client

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28
Q

Purpose of physical examination

A
  • to obtain baseline data
  • identify nursing diagnoses, collaborative problems and wellness diagnoses
  • monitor the status of a previously identified problem
    -to screen for health promotion
29
Q

Preparation for physical exam

A
  • prepare the environment: make the patient comfortable
  • Prepare the client: introduce yourself, explain what you will be doing
30
Q

Positions during the physical examine

A
  • Sitting
  • fowlers
  • prone
    -supine
  • lateral(side laying)
  • Sims(rectal exam)
  • Lithotomy
31
Q

Physical assessment techniques

A
  • inspection
  • palpation
  • percussion
  • Auscultation
32
Q

Inspection

A

visual examinations, observing, inspecting the area, exposing only what you need to see, can use light instruments, DO NOT RUSH!!

33
Q

Palpation

A
  • Using touch to gather information
    from different parts of hands to detect diff. characteristics
  • warm hands and short fingernails
  • look for edemas and uncomfortabilities
34
Q

Percussion

A

Tap skin striking surface with fingertips to vibrate underlying tissues and organs
- flatness= muscle or bone
- dullness= liver or heart
- resonance= hollow/ normal lung
- Hyper-resonance= lung with emphysema
- Tympany= stomach was gas(air)

35
Q

Auscultation

A
  • Listening to sounds that the body generates
  • direct( w/ stethoscope) or indirect(w/o stethoscope)
  • pitch, intensity, duration, quality
36
Q

Components of a general survey

A
  1. Physical appearance and behavior
  2. Body Type and posture
  3. Gait and movement
  4. Speech
  5. Mental State and Affect
  6. Dress, grooming, and hygiene
  7. Vital signs
  8. Height and weight
37
Q

Why is a general survey important?

A
  • initial impressions gained from preliminary observations direct the nurse to further examination
  • requires attention to detail
38
Q

Physical appearance and behavior

A
  • a variety of general observations about the patient; age, gender, race, and culture
  • identify signs of distress
  • does the patient appear healthy?
  • note the color of skin, any lesions/ sunburn
39
Q

Body Type and Posture

A
  • observe body posture, and body symmetry, and observe for evidence of spinal deformities
  • observe general impression of nutrition(well-nourished, overweight)
  • Observe evidence of distress( sitting in tripod position, S.O.B.
  • Do they assume a comfortable position
  • Any guarding or splinting an area that may indicate pain
40
Q

Gait and Movement

A

-Observe gait; balanced and smooth symmetry
- do arms swing freely?
- does the patient require assistive devices?
- Note ease of movement or struggle
- is their any limitations?

41
Q

Speech

A

-Is there difficulty with speech?
- Listen for tone, pace, quality, vocabulary and sentence structure
- do they respond appropriately
- any hesitations or language challenges

42
Q

Mental status and affect

A
  • determine the level of consciousness
  • orientation to time, place, person and situation
  • is the client disorientated?
  • what is the client’s mood?
43
Q

Dress, grooming, and hygiene

A
  • is the patient clean and well-groomed?
  • Any odors?
  • Are they dressed appropriately for the season?
44
Q

Vital signs

A
  • temperature
  • blood pressure
  • Pulse( heart rate)
  • Respirations & pulse ox
  • PAIN!
45
Q

Normal values

A

newborn: 130 bpm, 30-60 resp., 80/40
Adult: 80bpm, 12-20 resp., <120/<80
Older Adult: 8, 12-20 resp., 120/80-160/95

46
Q

Temperature

A
  • Reflects the balance between the heat produced and the heat lost from the body and is measured in heat units called degrees
  • F= 96.8-100.0 &C= 36-38
    -Auxillary= 98.1
  • oral= 99.1
  • rectal= 100.1
47
Q

Documenting temperature

A
  • Always document the route
  • single reading doesn’t always mean a fever
    Febrile: fever afebrile: no fever
48
Q

Measurement of temperature

A
  • oral - Surface - Core measurement
  • auxiliary - tympanic
  • DOCUMENT CORRECTLY
49
Q

important principle ofTympanic Measurement

A
  • senses body heat in the form of infrared energy given off by a heat source in the ear canal
  • Tug ear up and back(adults)
  • down(children)
50
Q

Heart rate(pulse)

A
  • wave a blood created by contraction of the left ventricle of the heart
  • peripheral: away from the heart
  • Apical: central pulse located at apex of the heart
    60-100bpm average
51
Q

Pulse Locations

A

Radial: radial side of forearm at the wrist
Brachial(elbow) and Carotid(neck) arteries

52
Q

Pulse characteristics

A

-rhythm: dysrhythmia or arrhythmia
- volume/ quality: weak/ strong
: Ease of access
- Elasticity of the arterial wall

53
Q

Respirations

A
  • counting the number of ventilatory cycles, inhalation, and exhalation, each minute
    -inspiration: active process
    -expiration: passive process
54
Q

Respiration Characteristics

A
  • Apnea: cessation of breathing
  • Tachypnea: quick shallow breathing
  • Bradypnea: abnormally slow breathing
    -rate
  • rhythm
  • volume/depth
  • ease or effort
55
Q

Blood pressure

A

the measure of the pressure exerted by the blood as it flows through the arteries

56
Q

Systolic pressure

A

Pressure of the blood as a result of contraction of the ventricles, that is pressure at the height of the blood wave
- Top number

57
Q

Diastolic pressure

A

Pressure when the ventricles are at rest, that is the lower pressure, present at all times within the arteries
-Bottom number

58
Q

Pulse pressures

A

The difference between diastolic and systolic pressures

59
Q

Factors that determine blood pressure

A
  • Pumping ability of the heart
  • Peripheral vascular resistance
  • Blood viscosity
  • blood volume
60
Q

What can affect blood pressure

A

-age -race -nervous system
- medications -gender - caffeine
- crossed legs - body position

61
Q

Orthostatic Blood Pressure

A
  • Drop of 20mm/Hg or more systolic or a drop of 10 mm/Hg diastolic within 3 minutes after position change
  • supine, sitting, standing
62
Q

Maintaining healthy blood pressure

A

-eat a healthy diet with lots of fruits and veggies
- limit foods high in fat, salt, and sugar
- keep weight at a healthy level
- Don’t smoke or use nicotine
- limit caffeine and alcohol

63
Q

Pulse Oximetry

A
  • a noninvasive method of monitoring oxygenation with a device that measures oxygen saturation. The oximeter emits light and a photosensor is placed on the finger and measures the light passing through and calculates the oxygen saturation
  • > 90% average
  • > 95% expected
64
Q

Describe the best practice approaches to physical assessments in pediatric patients

A

infants: exam room warm, assess vitals while sleeping
Toddlers: most comfortable on the lap of a parent, more like a game, make them feel comfortable, and lots of praising
preschoolers: Has more fear, demonstrate on doll first, make them feel comfortable, will withdraw if they feel threatened
School-age: Develop rapport, ask about school/activities, thinking is concrete, avoid using medical jargon
Adolescents: Provide privacy, demonstrate respect, expose only areas that are needed, allow opportunities for questions with out caregiver

65
Q

Safety procedures for health assessment

A
  • hand hygiene
  • follow standard precautions
    -identify patient
  • provide privacy
  • position for safety and comfort
    -utilize proper body mechanics
  • document properly
66
Q

Standard precautions

A

-USE WITH ALL PATIENTS
- mask on properly
- donning and doffing properly

67
Q

Ways to prevent falls in healthcare facilities

A
  • admission assesses all patients for fall risks
  • utilize standard fall risk assessment tools
  • Purposely hourly rounding
  • Identify modifiable risk factors
  • place call light within reach
  • keep floors dry and room free of clutter
68
Q

Ways to prevent falls at home

A

NURS 2910 (16 decks)

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